Norra MacReady and Martha Kerr
July 27, 2010 (Vienna, Austria) — More than 13,000 clinicians, researchers, and public policy experts have signed a declaration calling for the global decriminalization of drug use and the implementation of evidence-based policies to halt the rampant spread of HIV infection among injecting drug users (IDUs).
Released here at AIDS 2010: XVIII International AIDS Conference, the document, known as the Vienna Declaration, states that in parts of Eastern Europe and Central Asia, where the spread of HIV is most rapid, infection "can be as high as 70% among people who inject drugs, and in some areas more than 80% of all HIV cases are among this group." Yet these countries have some of the most punitive antidrug laws in the world.
"The International AIDS Conference is a unique mix of advocacy, activism, and science that you don't see at other conferences," Evan Wood, MD, director of the Urban Health Research Initiative at the BC Centre for Excellence in HIV/AIDS in Vancouver, British Columbia, told Medscape Medical News. Dr. Wood was a coauthor of the Vienna Declaration.
The Vienna Declaration calls drug policy reform "a matter of urgent international significance" and states that the epidemic will continue to spread if more-effective policies are not adopted, said Stephen Rolles, MSc, senior policy analyst at the Transform Drug Policy Foundation, a think tank based in London, England.
"The conference...was shaped by the outpouring of support for the Vienna Declaration and the need for scientists to stand together to support illicit drug policies based on evidence instead of ideology," Dr. Wood observed.
In the 50 years since countries around the world have outlawed the manufacture and possession of certain types of drugs, "the situation in terms of any indicators you might choose — public health, human rights, criminal justice — has deteriorated," Mr. Rolles added.
"For a policy that specifically aims to create a drug-free world, to eradicate drug production, prevent drug supply, and eliminate drug use from the world, it's been a staggering failure. Every year since this policy was begun, we've moved further and further away from that goal," he continued.
"Using drugs in a certain way and in a certain environment criminalizes the lifestyle that tends to lead to the spread of HIV, and that's what the Vienna Declaration is focusing on," Mr. Rolles stated. "It's calling for a shift away from this get-tough criminal justice populism that has tended to define the debate, and move it towards a more pragmatic, evidence-based, public health, scientifically driven model."
The best evidence to date suggests that HIV-positive IDUs benefit most from a triple-pronged approach to treatment, consisting of opioid substitution therapy, needle and syringe programs, and antiretroviral therapy. These are the key elements of a harm-reduction approach, Mr. Rolles said, which acknowledges that some people may be unwilling or unable to abstain from use drugs and instead "focuses on reducing the harm associated with the use itself."
Outside of sub-Saharan Africa, IDUs account for about one third of HIV disease internationally. To stem the epidemic, countries and clinicians around the world must grant HIV-infected drug users access to adequate healthcare services without turning them into criminals, forced laborers, or pariahs.
Despite clear evidence that opioid substitution therapy works, it is not available in many of the countries in which the epidemic is worst. Worldwide, only 8 of every 100 IDUs have access to it.
"The science has really moved forward, but that there is either a lack of political will or worse when it comes to addiction," Dr. Wood added.
"Methadone is on the World Health Organizations List of Essential Medicines but is illegal in places like Russia, where other harm-reduction tools are also scarce. Not surprisingly, it is now estimated that more than 1 in 100 adult Russians is HIV infected," Dr. Wood pointed out.
"The health impacts of the war on drugs obviously go beyond HIV.... Incarceration is a huge problem, with 1 in 100 Americans now in prison, and obviously there is an intersection with HIV," Dr. Wood said. "One in 9 African-American males ages 25 - 35 is incarcerated in the United States on any given day, and obviously this is the population where HIV is spreading most rapidly in the United States.
"The Obama administration's lifting of the needle exchange ban federally and the announcement about allowing [the President's Emergency Plan for AIDS Relief] funding for needle exchange in advance of the meeting were obviously welcome," he added.
Daniel Wolfe, MPH, from the International Harm Reduction Program of the Open Society Institute in New York City, noted at the conference that 5 countries in particular — China, Vietnam, Russia, Ukraine, and Malaysia — claim 47% of all HIV-infected IDUs in low- and middle-income nations. In Russia, IDUs account for 83% of all HIV cases, and in Malaysia, they account for 70%. Yet only about 25% of the patients most in need are receiving antiretroviral therapy, and less than 2% have access to opioid substitution therapy.
Draconian policies against drugs and drug users often are motivated by the idea that adoption of harm-reduction policies is tantamount to approving of, or at least tolerating, drug use, said Mr. Rolles, who was not involved in the Lancet symposium.
"In some circles there's a saying that 'harm reduction equals harm facilitation.' Often this can be traced back to a moralistic, almost quasi-religious view of drugs as inherently evil that has not been closely scrutinized until recently," Mr. Rolles said. "And anyone who challenges this policy was seen as being on the side of evil, or at least on the side of [using] drugs."
The problem with prohibitionist policies is that they ignore the overwhelming evidence that the war on drugs has failed, Mr. Rolles added. As the Vienna Declaration states, "the international scientific community calls for an acknowledgement of the limits and harms of drug prohibition, and for drug policy reform to remove barriers to effective HIV prevention, treatment and care."
"There was a strong sentiment [at the conference] that WHO and UNAIDS have been largely marginalized within the UN system with respect to the problems of drug addiction and a hope that the declaration will help to change this," Dr. Wood said.
He continued, "My colleague and president of the International AIDS Society, Julio Montaner [professor of medicine and chair in AIDS Research at the University of British Columbia] announced that the declaration and all the endorsements would be delivered to Ban Ki-moon [secretary-general of the United Nations], although we are keep the timeline open on this because the declaration process is going to culminate when the meeting is in Washington, DC, at AIDS 2012.
"Certainly, the focus on drug addiction and drug policy was welcome by those working in this area, given how it has not received much attention in the past," said Dr. Wood. "However, the problems in Africa and elsewhere are obviously huge issues, [and] so certainly must be acknowledged. It was interesting how the different groups (eg, gay men, sex workers, those with HIV, drug users, etc) united under the banner of the need for a human rights approach [to HIV], and hopefully this will strengthen the overall effort to address the epidemic."
The Vienna Declaration can be viewed on its own Web site.
Dr. Wood is the brother of an editor at theheart.org, a Web site owned by WebMD, which also owns Medscape. None of the speakers have disclosed any other relevant financial relationships.
AIDS 2010: XVIII International AIDS Conference: Symposium TUSY07. Presented July 20, 2010.
Lancet. Published online July 20, 2010.
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